How is gastroesophageal reflux disease in children treated?

Treatment for gastroesophageal reflux disease consists of 3 components:

1. a complex of non-medicamentous effects, mainly the normalization of the way of life, the regime of the day and nutrition;
2. conservative therapy;
3. surgical correction.

[1], [2], [3], [4], [5], [6], [7], [8],

Treatment of gastroesophageal reflux disease in young children

According to the recommendations of ESPGHAN (2005), the treatment of regurgitation consists of several consecutive stages.

• Postural therapy (treatment by position): the baby should be fed in a sitting position, keeping at an angle of 45-60 °. After feeding, the position should be kept for at least 20-30 minutes, then the child can be laid on the back, raising the head end by 30 °.
• Dietary correction: it is necessary to increase the number of feedings by decreasing the single food volume. With natural feeding, thickeners of breast milk are used (mixture "Bio-rice broth", HIPP). Children older than 2 months can be given before feeding more dense food (1 teaspoon dairy-free rice porridge). Children with artificial feeding are shown mixtures with thickeners that contain gum (gluten of locust bean), for example, Nutrilon AP, Fresov, Human AR, Nutrilak AR or rice starch (amylopectin), for example, "Samper- Lemolak "," Enfamil AR ".
• Prokinetic agents: domperidone (motilium, motilac) 1-2 mg / kg per day in 3 doses or metoclopramide (cerucal) at 1 mg / kg per day in 3 doses 30 minutes before meals for 2-3 weeks.
• Antacids (with esophagitis I degree): fosfalugel 1 / 4-1 / 2 sachets 4-6 times a day between feedings for 3-4 weeks.
• Antisecretory drugs (with esophagitis II-III degree): proton pump inhibitors - omeprazole (losek) at 1 mg / kg per day 1 time per day for 30-40 minutes before feeding for 3-4 weeks. Data from foreign multicenter studies prove the safety of proton pump inhibitors in prescribing to young children; ESPGHAN allows you to recommend omeprazole to children from 6 months of age.

Treatment of gastroesophageal reflux disease in older children

An important role in the treatment is the correction of the child's lifestyle.

• Raising the head end of the bed at least 15 cm. This measure reduces the duration of acidification of the esophagus.
• Introduction of dietary restrictions:
  • reduction in fat in the diet (cream, butter, fatty fish, pork, goose, duck, lamb, cakes), since fats lower the tone of the lower esophageal sphincter;
  • increase the protein content in the diet, as proteins increase the tone of the lower esophageal sphincter;
  • decrease in the volume of food;
  • Restriction of irritating products (juices of citrus fruits, tomatoes, coffee, tea, chocolate, mint, onion, garlic, alcohol, etc.) to prevent direct damage to the esophagus mucosa and decrease the tone of the lower esophageal sphincter.
• Decreased body weight (with obesity) to eliminate the alleged cause of reflux.
• The development of a habit is not before going to bed, not lying after eating to reduce the volume of gastric contents in a horizontal position.
• Elimination of tight clothing, tight belts to avoid increased intra-abdominal pressure, enhancing reflux.
• Prevention of deep slopes, prolonged stay in a bent position (pose "gardener"), lifting weights of more than 8-10 kg in both hands, physical exercises associated with overstrain of the muscles of the abdominal press.
• Restriction of taking medications that reduce the tone of the lower esophageal sphincter or slowing the peristalsis of the esophagus (sedatives, hypnotics, tranquilizers, slow calcium channel blockers, theophylline, anticholinergics).
• Exclusion of smoking, significantly reducing the pressure of the lower esophageal sphincter.

Medicamentous treatment of gastroesophageal reflux disease in children

Gastroesophageal reflux without esophagitis, endoscopically negative variant, as well as gastroesophageal reflux with reflux esophagitis of the 1st degree:

• antacid preparations mainly in the form of gel or suspension: aluminum phosphate (phosphalugel), maalox, almagel - 1 dose 3-4 times a day 1 hour after meals and at night for 2-3 weeks. Gaviscon for children 6-12 years old is prescribed by mouth 5-10 ml after meals and before bedtime;
• prokinetic means: domperidone (motilium, motilac) 10 mg 3 times a day, metoclopramide (cerucal) 10 mg 3 times a day for 30 minutes before meals for 2-3 weeks;
• symptomatic treatment (eg, associated with gastroesophageal reflux of respiratory pathology).

Gastroesophageal reflux with reflux esophagitis of II degree:

• antisecretory drugs of the proton pump inhibitor group: omeprazole (losek, omez, gastrozole, ultop, etc.), rabeprazole (pariet), esomeprazole (nexium) 20-40 mg per day for 30 min before meals for 3-4 weeks;
• prokinetic means within 2-3 weeks.

Gastroesophageal reflux with reflux esophagitis of III-IV degree:

• antisecretory drugs of the proton pump inhibitor group for 4-6 weeks;
• prokinetic funds within 3-4 weeks;
• cytoprotectors: sucralfate (venter) for 0.5-1 g 3-4 times a day for 30 minutes before meals for 3-4 weeks.

Taking into account the role of the nervous system (especially in the vegetative department) in the pathogenesis of gastroesophageal reflux, signs of autonomic dystonia or pathology of the central nervous system, the purpose of complex treatment taking into account all links of the pathogenesis of gastroesophageal reflux disease is shown:

• vasoactive drugs (vinpocetine, cinnarizine);
• nootropics (gopanthenic acid, piracetam);
• preparations of complex action (instenona, phenibut, glycine, etc.):
• sedative preparations of plant origin (preparations of motherwort, valerian, hops, St. John's wort, mint, hawthorn).

An example of a basic curative program:

• phosphalugel - 3 weeks;
• motilium - 3-4 weeks.

Repeat the course of treatment with prokinetic agents after 1 month.

The question of the expediency of prescribing antisecretory drugs (blockers of H ₂ -receptor histamine or inhibitors of the proton pump) is solved individually, taking into account the prevailing clinical symptom complex, the results of the study of the acid-forming function of the stomach (hypersecretory status), daily pH monitoring (severe acid gastroesophageal reflux) insufficient effectiveness of the basic treatment program.

Physiotherapy

They use phonenes with sinusoidal-modulated currents with cerucal on the epigastric region, decimeter waves on the collar zone, the Electroson apparatus.

In the period of remission, children are recommended to have sanatorium-resort treatment in institutions of the gastrointestinal profile.

Surgical treatment of gastroesophageal reflux disease

Fundoplication is usually carried out by the method of Nissen or Tal. Indications for fundoplication:

• a pronounced clinical picture of gastroesophageal reflux disease, which significantly reduces the patient's quality of life despite repeated courses of medical antireflux treatment;
• long-lasting endoscopic symptoms of reflux-esophagitis of III-IV degree against the background of repeated courses of treatment;
• complications of gastroesophageal reflux disease (bleeding, stricture, Barrett's esophagus);
• a combination of gastroesophageal reflux disease with hernia of the esophageal opening of the diaphragm.

Antiretroviral treatment of gastroesophageal reflux disease in children

The appointment of antacid and prokinetic agents, antisecretory drugs in the period of persistent clinico-morphological remission is not shown, but it is possible to prescribe medications of a symptomatic series for admission to patients "on demand".

With esophagitis III-IV degree prolonged administration of inhibitors of proton pump (1-3 months) in a supportive (half) dose is shown. With an anti-relapse goal, autumn-spring courses of phyto- and vitamin therapy, balneotherapy are shown.

Children with gastroesophageal reflux disease in the stage of incomplete clinico-endoscopic remission are recommended to practice physical education in the main group without putting standards for the time and without participation in competitions; Classes in the main group are allowed in the stage of complete clinical endoscopic remission.

[9], [10], [11]

Dispensary supervision

Monitoring of a sick child up to the transfer to an adult polyclinic network is carried out by the district pediatrician and the district gastroenterologist. The frequency of the appointment of examinations depends on the clinical endoscopic data and is at least 2 times a year.

The frequency of fibroesophagogastroduodenoscopy is determined individually based on clinical and anamnestic data, the results of previous endoscopic studies and the duration of clinical remission.

• With endoscopically negative form of gastroesophageal reflux disease and reflux esophagitis I degree, the study is shown only if the disease worsens or when transferred to an adult network.
• In case of gastroesophageal reflux disease and / or reflux-esophagitis of II-III degree, fibroesophagogastroduodenoscopy is performed once a year, or with exacerbation of the disease, and also when transferred to an adult network.
• In case of gastroesophageal reflux disease with reflux esophagitis of the fourth degree (ulcer of the esophagus, Barrett's esophagus), the study is performed every 6 months in the first year of observation and every year in the subsequent (under condition of clinical remission of the disease).

The study of the secretory function of the stomach (pH-metry) is performed no more often than once in 2-3 years. Necessity and timing of repeated daily pH monitoring are determined individually.

[12], [13], [14]